Failure to Notify Physician and Document Assessment After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for change in condition and abuse/neglect clinical protocol for one resident. The resident, who had dementia, major depressive disorder, anxiety disorder, and a history of right femur fracture, was assessed as having severe cognitive impairment and being dependent for ADLs including toileting, bathing, and bed mobility. On 3/14/2026, the resident reported an allegation of abuse, stating that during a shower a CNA hit her on the head. A Change of Condition (COC) form dated 3/14/2026 showed that the primary care physician (PCP) was notified of the allegation that day at 4:24 p.m., but the COC did not document that a full head-to-toe assessment was completed, did not record any discoloration or bruising, and did not indicate that the PCP was notified of any such findings. In interviews, RN 1 stated that he did perform a full body assessment after the allegation and found a finger-length bluish discoloration on the resident’s left hip on 3/14/2026. However, this skin assessment was not entered into the resident’s medical record and was instead documented on a separate paper form kept in the abuse investigation file. RN 1 also stated he was unable to reach the resident’s PCP regarding both the allegation of abuse and the skin discoloration and did not notify the Medical Director. The DON confirmed that a head-to-toe skin assessment should be completed and documented for all abuse allegations, that any skin discolorations should be reported to the PCP, and that staff should contact the Medical Director if the PCP cannot be reached. Facility policies titled “Change in a Resident’s Condition or Status” and “Abuse and Neglect – Clinical Protocol” required the nurse to assess the resident, document injury assessment findings, and report those findings to the physician after an accident, incident, or allegation of abuse, which was not fully done in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.